Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems

6.4 General Barriers to Treatment Access: Literature Review

Most people with alcohol/drug use problems do not enter treatment (Grant, 1997). Of those who do, the ratio of men accessing specialized treatment is much higher than for women (Schober and Annis, 1996). There is evidence in the literature that a woman's pathway to treatment is unique and her experience and interpretation of barriers complex.

There is also extensive literature which identifies barriers to treatment experienced by women with alcohol/drug use problems. Although these barriers are categorized somewhat differently, a summary of barriers applying to all women is presented below: (Beckman and Amaro, 1986; Thom, 1986; Thom, 1986, 1987; Cooper, 1991; Wilsnack, 1991; Cunningham and Sobell,1993; Ja and Aoki, 1993; Planning for Change, 1993; Saskatchewan Alcohol and Drug Abuse Commission, 1993; Allen, 1994; Beckman, 1994b; Schober and Annis, 1996; Copeland, 1997; Finkelstein et al., 1997; Grant, 1997; Klein et al., 1997).

The barriers described in the literature broadly reflect the themes identified by key experts, although the literature emphasizes to a greater degree barriers related to "gateways" or entry points into treatment.

6.4.1 Personal Barriers

The literature identifies the following personal/internal barriers which affect women's access to treatment.

• Shame and embarrassment related to social stigma and labelling. Society stigmatizes those who misuse alcohol and drugs (Beckman and Amaro, 1986; Copeland, 1997). This stigma is magnified for women. Drinking may be associated with "moral laxity or maternal deficiencies." Stigma and shame may also contribute to the difficulty women experience in defining themselves as having alcohol use problems (Smith, 1992).
• Lack of confidence in alcohol treatment and its effectiveness. Even when adults see the need for alcohol treatment, many do not access it. In a study of males and females with alcohol use problems, Grant (1997) found that a major reason for not accessing treatment was a lack of confidence in the alcohol treatment system and its effectiveness.
• A belief that people who use substances should be able to handle impacts and problems themselves. Grant (1997), in a study of men and women with alcohol use disorders, found that 30% of 964 subjects with alcohol use disorders did not consider entering treatment because they believed they should be "strong enough to help themselves." Twenty percent believed their drinking problem would get better by itself; 23% thought the problem was not serious enough to warrant help.
  

Thom (1987), in a study of gender differences in seeking treatment for alcohol problems, found that women did not regard alcohol as a primary problem and had considerable reservations about the relevance of treatment to their needs.

• Lack of information about treatment programs and resources. In an analysis of barriers to treatment, Allen (1994) identified lack of awareness of treatment programs as a major barrier for women. Grant noted that women are more likely to say they don't know where to go for help (than men).
  

If women are more likely to rely on referrals by family or friends or learn about the treatment programs through advertisements or word of mouth, then the results of this study suggest a need to expand the more conventional referral routes for women (Grant, 1997: 370).

• Experience of violence and abuse/need for safety. Copeland and Hall (1992) in a study of 160 women in treatment, noted that 86% experienced physical or sexual abuse at some time in their lives. Women who have experienced violence in their lives may have more stringent needs for a safe and secure environment which they worry cannot be met in treatment.
• Ways of viewing alcohol/drug problem/gateways into treatment. In general, women see alcohol/drug use as a response to social, mental health or health needs or issues. Women are less likely than men to perceive their drinking as source of difficulties (legal, financial, family or work-related) in their lives. Instead, they identify anxiety, depression and stressful events as contributors. Gomberg (as cited in Beckman, 1994b) reported that the most frequent reasons given by women for seeking treatment are depression, medical problems, problems with family relationships and feelings related to children leaving the home.

Because of these differences, women are less likely than men to initially seek help from alcohol or other chemical dependency services. Instead, women are more likely to consult their physician or mental health services when they have problems. Substance use problems may not be appropriately identified.

6.4.2 Interpersonal Barriers

Beckman and Amaro (1986) noted that women perceive greater social costs associated with entering alcohol treatment. Almost 50% (versus 20% of men) described problems with family, friends or money as disincentives to entering treatment.

Women also encounter more opposition from family and friends during the months prior to treatment entry. Studies also found that women are often encouraged to keep on drinking by spouses or partners who themselves have alcohol use problems (Wilsnack, 1991).

6.4.3 Structural and Program Barriers

Structural and program barriers also act as disincentives to women entering treatment. These barriers include:

• Limited program outreach. Swift and Copeland noted that treatment services often lack outreach or referral mechanisms which assist women to enter treatment.
  

(Program) responses could include improved outreach, referral networks or advertising of services specifically targeting women who may be unaware of the range of services. The provision of more detailed information about programs may allay any fears potential clients, their partners and/or families may have about what treatment involves. (Swift and Copeland, 1996:217)

• Inadequate referral systems. Women are not regularly referred from the generic mental health programs they initially access or from their personal physicians for a range of reasons, including the inability of professionals to screen for treatment and women's unwillingness to acknowledge problems associated with substance use (Mulford as cited in Smith, 1992).
• Costs associated with treatment. Women requiring treatment often have low incomes and limited economic resources. Direct costs of treatment, replacement of wages and treatment support costs (child care, transportation) may make treatment inaccessible to women (Beckman and Amaro, 1986).
• Treatment structured on basis of male treatment. The literature suggests that alcohol/drug treatment has commonly been structured to meet the needs of men rather than women (Wilke, 1994). This "male as norm bias" is manifested by a lack of woman-specific program elements, limited female staffing and restricted attention to women's values and ways of interacting. For example, Smith noted that women may be more responsive than men to multi-model programs which include support groups, attention to sexual abuse and spousal violence issues.

Traditional treatment programs tend to reflect traditional male values such as the importance of the male work ethos and the need for men to be in full-time employment. This may be communicated covertly through the organization of programs on a day-to-day basis (Smith, 1992:8)

• Attitudes of service providers. Vanicelli (as cited in Smith, 1992) noted that health care providers may share the same negative values toward women with substance use problems as the public at large, in particular, the belief that women with addiction problems have a poorer prognosis and are more difficult to treat.
• Misdiagnosis, lack of effective referral networks. General practitioners often misdiagnose patients with alcohol/drug problems. If alcohol/drug problems are not clearly identified in the initial stages of intake, women are unlikely to be referred to specialized treatment services. In a study of caseload practice, Mulford (as cited in Smith, 1992) found that only 10% of women (requiring treatment) had been referred to treatment by their doctors; instead, nearly 50% had been prescribed medication for nerves or menopause.

There is also an increased incidence of depression, anxiety and post traumatic stress disorders among women with alcohol use problems. The presence of these disorders means that women are more likely to seek help at general mental health centres which may not be a direct pathway to treatment (Schober and Annis, 1996). Even with identification and referral, women may be less willing to identify their problems as substance abuse related.

• Lack of child care services and resources. The lack of child care services or resources to pay for children services are primary reasons why women do not access treatment services. Women may also fear losing their children to welfare authorities. In a survey of respondents who provide treatment, Wilsnack (1991) identified responsibility for dependent children as one of the primary barriers for women. Women are more likely than men to utilize alcohol treatment agencies that provide child care and/or treatment for children (Beckman and Kocel as cited in Schober and Annis, 1996).
  

Other structural/program barriers identified in the literature include:

• lack of women on staff (Allen, 1994; Beckman and Kasl as cited in Schober and Annis, 1996);
• rigid abstinence requirements (which are too inflexible for most women);
• failure to provide consistent staffing (Schober and Annis, 1996);
• placement of settings (in stigmatizing psychiatric settings) (Schober and Annis, 1996);
• low morale and commitment of staff (Schober and Annis, 1996);
• wait lists (Schober and Annis, 1996).
  

6.5 Barriers of Specific Groups: Literature Review

The literature does not address, in detail, barriers experienced by all the sub-groups identified in this study. However, a summary of available literature related to some of these groups is presented below.

6.5.1 Pregnant and Parenting Women

Finkelstein (1994), in a study of treatment needs of pregnant women, identified two major barriers experienced by this group.

• Negative attitudes which stigmatize, reject and blame women. Pregnant and parenting women are more heavily stigmatized by society. Rejection and blame are commonly expressed by community and health and social service personnel.
• A lack of treatment and related resources specifically geared to pregnant and parenting women. Finkelstein noted that there is a lack of treatment facilities which:
  • can handle medical issues (such as appropriate detoxification) during pregnancy;
  • can address perinatal issues;
  • can provide infant care or care to other children while the mother is in treatment;
  • address cost factors;
  • provide adequate training to staff.

In a study of 47 women (40% of whom were Aboriginal) who had problems with alcohol or other drugs and who were pregnant or parenting (children under the age of 16) in Vancouver and Prince George, British Columbia, Poole and Issac (1999) described seven main barriers identified by respondents. These included both personal and structural barriers:

• shame (66%);
• fear of losing children if women identified themselves as needing treatment (62%);
• fear of prejudicial treatment on the basis of motherhood/pregnancy status (60%);
• feelings of depression and low self-esteem (50%);
• belief women could handle the problem without treatment (55%);
• lack of information as to what was available (55%);
• waiting lists for treatment services (53%).
  

6.5.2 Women with Concurrent Substance Use and Mental Health Disorders

• Fragmentation of treatment system. Grella (1996) noted that differences in the philosophy or approaches of the mental health and substance abuse treatment systems often create additional barriers for women with concurrent mental health disorders. Differences exist in the following areas:
  - the definition and interpretation of the problem;
  - the interpretation of client motivation and determination of client "readiness" for treatment;
  - accepted methods of treatment and treatment modalities;
  - staff attitudes toward using drugs as treatment support;
  - treatment duration;
  - staff characteristics, skills and training.

These differences result in the lack of a coordinated approach, inadequate diagnoses and inconsistencies in treatment provision.

6.5.3 Aboriginal Women

There is a lack of specific data that identifies barriers experienced by Aboriginal women. Results from a Canadian national conference on women and chemical dependencies (Planning for Change, 1993) concluded that the following barriers were most significant for this group:

• wait lists;
• lack of child care services;
• language barriers/lack of translation services;
• poor referral networks;
• family responsibilities not addressed;
• stigma;
• lack of family support.
  

6.5.4 Ethno-cultural Minority Women

A Health Canada study of immigrant women and substance use (Health Canada,1996a) identified a number of issues related to service access and barriers for an immigrant woman experiencing a substance use problem. These included lack of expertise and resources on the part of both mainstream health organizations and immigrant aid or ethno-cultural organizations to address women's substance use problems; lack of information or misinformation about availability of culturally appropriate services, which often resulted in inappropriate referrals or women being referred back and forth between a mainstream health organization and an ethno-cultural organization; unrealistic expectations by mainstream organizations about the ability and resources of ethno-cultural/immigrant aid organizations to provide substance abuse treatment.

As a result of these barriers, the report noted that immigrant women with substance use problems may receive no help or information, or if they do it may be in an unfamiliar language or in their own language but from people who are inexperienced in the area of substance use problems, or from a perspective that does not take into account their cultural reality and/or their needs as women.

Ja and Aoki (1993), in a study of barriers to treatment for Asian-American^* women identified some additional barriers:

* These conclusions may not apply to other ethnno-cultural minority groups.

• Lack of substance use prevalence data. Asians have been stereotyped as a "model minority" with the generally accepted view that they use substances at a lower rate than others. For this reason, many statistical surveys exclude them and other ethno-cultural minority groups. However, evidence suggests that there are diverse rates of use among different Asian sub-groups (Chi as cited in Ja and Aoki, 1993).
• Cultural expectations or values. Because of cultural beliefs or practices, families or ethnic communities may ignore, deny or dismiss alcohol or drug problems or discourage women from seeking treatment in the outside community.
• A lack of culturally sensitive programs. The authors concluded that simply adapting mainstream programs to ethnic minorities may not be adequate to serve the needs of women. Programs need components that speak directly to ethnic practices and values. Additional components include a strong focus on program orientation (clearly describing program goals), content and expected outcomes, incorporation of non-confrontational approaches, family counselling and creative elements (art, music, dance or theatre).
• Lack of specialized addiction treatment programs. Treatment in ethno-cultural minority communities is often provided by generic, unspecialized and unqualified agencies.
• Poor/confused motivation within client group related to shame and family denial.
• A lack of programs which respect or build on the family unit.
• Inadequate/untrained referral sources to facilitate referrals to treatment.
• Reliance on informal family problem-solving mechanisms.
  

6.5.5 Women Living in Rural Communities

A Health Canada study: Rural Women and Substance Use: Issues and Implications for Programming (Health Canada, 1996b), identified a number of program and service issues, including:

• Lack of appropriate services for women. This may include lack of the service itself or understaffed or under-supplied services, providing a limited range of referral options.
• Lack of women-centred services. In rural areas, assessment and treatment services may reflect a traditional or male model of intervention; also, existing services may have a single approach (e.g. abstinence), and not provide harm reduction services.
• Inadequate counselling for sexual and physical abuse. In particular, lack of treatment for women abused as children is a major problem.
• Professionals lack of knowledge about the reality of rural women's lives. "People with problems want to talk to their peers" (Health Canada, 1996c). Rural women with substance use problems may have difficulty finding a helping person who is familiar with rural life and its problems.
  

Additional barriers identified in a study of illegal drug use among rural adults (Robertson and Donnermeyer, 1997) included distance and lack of transportation as major barriers to treatment utilization. The chronic poverty conditions within many rural areas makes access by clients to early intervention difficult. Costs associated with treatment are also a disincentive (e.g. transportation, payment for board and lodging in residential programs).

6.5.6 Women in Prison

A general lack of treatment or related programs for women within correctional settings was described as the major barrier for this sub-group.

In Canada, 56% of the female prison population is estimated to have been involved in drug-related crimes (Lightfoot and Lambert as cited in Lightfoot et al., 1996b). At the federal level, Correctional Service of Canada provides treatment both at the institutional and community level. However, no specific information was available on the extent, scope and content of treatment for women in provincial correctional settings.

A recent publication, Substance Abuse Treatment for Women Offenders: Guide to Promising Practices, from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), (1999), summarizes the research on women offenders with substance abuse problems and provides guidelines for women-centred treatment in a correctional setting, including the system issues and barriers that need to be addressed. This publication is available on-line as well as in hard copy from SAMHSA.

6.5.7 Street Involved Homeless Women

No specific data related to barriers experienced by women who are street involved or homeless were found in the literature. Milby et al., in a study of both male and female homeless substance abusers, suggested that the state of homelessness fundamentally compromises a person's ability to respond favourably to treatment.

Perhaps the need for some rest and sleep, food and shelter from weather are prepotent over the need for treatment of a substance abuse problem. (Milby et al., 1996:40)

This study showed that day treatment plus work therapy and housing support led to improved treatment outcomes. The provision of a multi-dimensional support system appears to be most critical for dismantling barriers to this group.